sleep apnea: diagnosis and treatment · pdf filesleep testing for obstructive sleep apnea ......
TRANSCRIPT
Page 1 of 12
UHC MA Coverage Summary: Sleep Apnea: Diagnosis and Treatment
Proprietary Information of UnitedHealthcare. Copyright 2018 United HealthCare Services, Inc.
Coverage Summary
Sleep Apnea: Diagnosis and Treatment
Policy Number: S-003 Products: UnitedHealthcare Medicare Advantage Plans Original Approval Date: 08/23/2007
Approved by: UnitedHealthcare Medicare Benefit Interpretation Committee Last Review Date: 01/16/2018
Related Medicare Advantage Policy Guidelines:
Continuous Positive Airway Pressure (CPAP) Therapy for
Obstructive Sleep Apnea (OSA) (NCD 240.4) and Other
Respiratory Assist Devices (RAD)
Electrosleep Therapy (NCD 30.4)
Sleep Testing for Obstructive Sleep Apnea (OSA) (NCD
240.4.1)
This information is being distributed to you for personal reference. The information belongs to UnitedHealthcare and unauthorized
copying, use, and distribution are prohibited. This information is intended to serve only as a general reference resource and is not
intended to address every aspect of a clinical situation. Physicians and patients should not rely on this information in making health
care decisions. Physicians and patients must exercise their independent clinical discretion and judgment in determining care. Each
benefit plan contains its own specific provisions for coverage, limitations, and exclusions as stated in the Member’s Evidence of
Coverage (EOC)/Summary of Benefits (SB). If there is a discrepancy between this policy and the member’s EOC/SB, the
member’s EOC/SB provision will govern. The information contained in this document is believed to be current as of the date
noted.
The benefit information in this Coverage Summary is based on existing national coverage policy, however, Local Coverage
Determinations (LCDs) may exist and compliance with these policies are required where applicable.
INDEX TO COVERAGE SUMMARY
I. COVERAGE
1. Diagnosis of Obstructive Sleep Apnea (OSA)
a. Oximetry Testing
b. Polysomnography and Sleep Studies
2. Treatment of Sleep Apnea and Examples
a. Continuous Positive Airway Pressure (CPAP)
b. Respiratory Assist Devices including Bilevel Positive Airway Pressure (BiPAP)
c. Mandibular Devices/Oral Appliances
d. Surgical Treatment
1) Radiofrequency Submucosal Ablation of the Soft Palate and/or Tongue Base
2) Other Surgical Treatments
3. Examples of Noncovered Services
a. Surgery/Treatment - Dental in Nature
b. Electrosleep Therapy
c. Implantable Hypoglossal Nerve Stimulation (HGNS)
II. DEFINITIONS
III. REFERENCES
IV. REVISION HISTORY
V. ATTACHMENTS
I. COVERAGE
Page 2 of 12
UHC MA Coverage Summary: Sleep Apnea: Diagnosis and Treatment
Proprietary Information of UnitedHealthcare. Copyright 2018 United HealthCare Services, Inc.
Coverage Statement: The diagnosis and treatment of obstructive sleep apnea are covered when
Medicare coverage criteria are met.
DME Face to Face Requirement: Effective July 1, 2013, Section 6407 of the Affordable Care Act
(ACA) established a face-to-face encounter requirement for certain items of DME (including
respiratory assist devices). For DME Face to Face Requirement information, refer to the Coverage
Summary for Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-
Foot Orthotics) and Medical Supplies Grid.
Guidelines/Notes:
1. Diagnosis of obstructive sleep apnea (OSA) is covered. Examples of covered diagnostic services
include, but are not limited to:
a. Oximetry Testing
Medicare does not have a National Coverage Determination (NCD) for Oximetry
Testing.
Local Coverage Determinations (LCDs) exist and compliance with these LCDs is
required where applicable. For state-specific LCDs, refer to the LCD Availability Grid
(Attachment A).
For states with no LCDs, refer to the following Coverage Summary guidelines below;
based on Palmetto LCD for Respiratory Therapy and Oximetry Services (L33446).
Committee approval date: January 16, 2018
Accessed April 4, 2018
IMPORTANT NOTE: After searching the Medicare Coverage Database, if no state LCD or
Local Article is found, then use the Coverage Summary guidelines below.)
Coverage Summary Guidelines for state with no LCDs:
Medically necessary reasons for pulse oximetry include:
Patient exhibits signs or symptoms of acute respiratory dysfunction such as:
o Tachypnea
o Dyspnea
o Cyanosis
o Respiratory distress
o Confusion
o Hypoxia
Patient has chronic lung disease, severe cardiopulmonary disease, or neuromuscular
disease involving the muscles of respiration, and oximetry is needed for at least one of
the following reasons:
o Initial evaluation to determine the severity of respiratory impairment.
o Evaluation of an acute change in condition.
o Evaluation of exercise tolerance in a patient with respiratory disease.
o Evaluation to establish medical necessity of oxygen therapeutic regimen.
Patient has sustained severe multiple trauma or complains of acute severe chest pain.
Patient is under treatment with a medication with known pulmonary toxicity, and
oximetry is medically necessary to monitor for potential adverse effects of therapy.
Note: Codes 94760 and 94761 are bundled by the Correct Coding Initiative (CCI) with
critical care services. Therefore, codes 94760 and 94761 cannot be paid separately when
billed with critical care (codes 99291 and 99292).
Page 3 of 12
UHC MA Coverage Summary: Sleep Apnea: Diagnosis and Treatment
Proprietary Information of UnitedHealthcare. Copyright 2018 United HealthCare Services, Inc.
CPT code 94762 is considered medically necessary when performed for any of the following
reasons:
The patient has a condition for which intermittent arterial blood gas sampling is likely to
miss important variations.
The patient has a condition resulting in hypoxemia and there is a need to assess
supplemental oxygen requirements and/or a therapeutic regimen.
For Continuous Overnight Oximetry (94762), the patient's record must document that the
oximeter is preset and self- sealed and cannot be adjusted by the patient. In addition, the
device must provide a printout that documents an adequate number of sampling hours,
percent of oxygen saturation and an aggregate of the results. This information must be
available if requested. In all instances, there must be a request documented in the medical
record from the treating physician for these services.
The results of tests performed by a durable medical equipment supplier or his employees to
qualify patients for home oxygen service are not covered.
b. Polysomnography and Sleep Studies
Effective for claims with dates of service on and after March 3, 2009, the following tests are
considered reasonable and necessary:
1) Type I PSG is covered when used to aid the diagnosis of OSA in beneficiaries who
have clinical signs and symptoms indicative of OSA if performed attended in a sleep
lab facility.
2) Type II or Type III sleep testing devices are covered when used to aid the diagnosis of
OSA in beneficiaries who have clinical signs and symptoms indicative of OSA if
performed unattended in or out of a sleep lab facility or attended in a sleep lab facility.
3) Type IV sleep testing devices measuring three or more channels, one of which is
airflow, are covered when used to aid the diagnosis of OSA in beneficiaries who have
signs and symptoms indicative of OSA if performed unattended in or out of a sleep lab
facility or attended in a sleep lab facility.
4) Sleep testing devices measuring three or more channels that include actigraphy,
oximetry, and peripheral arterial tone, are covered when used to aid the diagnosis of
OSA in beneficiaries who have signs and symptoms indicative of OSA if performed
unattended in or out of a sleep lab facility or attended in a sleep lab facility.
See the NCD for Sleep Testing for Obstructive Sleep Apnea (OSA) (240.4.1). (Accessed
April 4, 2018)
Local Coverage Determinations exist and compliance with these policies is required
where applicable. See the following LCDs at http://www.cms.gov/medicare-coverage-
database/overview-and-quick-search.aspx (Accessed April 4, 2018)
o Polysomnography
o Polysomnography and Other Sleep Studies
o Polysomnography and Sleep Testing
o Outpatient Sleep Studies
o Medicine: Home Sleep Testing (HST)
5) Home Sleep Studies or Polysomnography (G0398, G0399, G0400, 95800, 95801,
and 95806)
Page 4 of 12
UHC MA Coverage Summary: Sleep Apnea: Diagnosis and Treatment
Proprietary Information of UnitedHealthcare. Copyright 2018 United HealthCare Services, Inc.
Medicare does not have a National Coverage Determination (NCD) specifically
for home sleep testing or polysomnography.
Local Coverage Determinations (LCDs)exist for all 50 states and compliance with
these LCDs is required where applicable. For state-specific LCDs, see the LCD
Availability Grid (Attachment D).
Committee approval date: January 16, 2018
Accessed April 4, 2018
2. Treatment of sleep apnea; examples include, but are not limited to:
a. Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) is a non-invasive technique for providing
single levels of air pressure from a flow generator, via a nose mask, through the nares. The
purpose is to prevent the collapse of the oropharyngeal walls and the obstruction of airflow
during sleep, which occurs in OSA.
The use of CPAP is covered when used in adult patients with diagnosis of under the
following situations:
1) The use of CPAP is covered under Medicare when used in adult patients with OSA.
Coverage of CPAP is initially limited to a 12-week period to identify beneficiaries
diagnosed with OSA as subsequently described who benefit from CPAP. CPAP is
subsequently covered only for those beneficiaries diagnosed with OSA who benefit
from CPAP during this 12-week period.
2) The provider of CPAP must conduct education of the beneficiary prior to the use of
the CPAP device to ensure that the beneficiary has been educated in the proper use of
the device. A caregiver, for example a family member, may be compensatory, if
consistently available in the beneficiary's home and willing and able to safely operate
the CPAP device.
3) A confirmed diagnosis of OSA for the coverage of CPAP must include a clinical
evaluation and a positive:
attended polysomnography (PSG) performed in a sleep laboratory; or
unattended home sleep test (HST) with a Type II home sleep monitoring device; or
unattended HST with a Type III home sleep monitoring device; or
unattended HST with a Type IV home sleep monitoring device that measures at
least 3 channels
4) The sleep test must have been previously ordered by the beneficiary’s treating
physician and furnished under appropriate physician supervision.
5) An initial 12-week period of CPAP is covered in adult patients with OSA if either of
the following criterion using the Apnea-Hypopnea Index (AHI) or Respiratory
Disturbance Index (RDI) are met:
AHI or RDI greater than or equal to 15 events per hour, or
AHI or RDI greater than or equal to 5 events and less than or equal to 14 events
per hour with documented symptoms of excessive daytime sleepiness, impaired
cognition, mood disorders or insomnia, or documented hypertension, ischemic
heart disease, or history of stroke.
(Refer to #2.a.1 above for the description and criteria for the initial 12- week trial
period for CPAP.)
6) The AHI is equal to the average number of episodes of apnea and hypopnea per hour
Page 5 of 12
UHC MA Coverage Summary: Sleep Apnea: Diagnosis and Treatment
Proprietary Information of UnitedHealthcare. Copyright 2018 United HealthCare Services, Inc.
and must be based on a minimum of 2 hours of sleep recorded by polysomnography
using actual recorded hours of sleep (i.e., the AHI may not be extrapolated or
projected). If the AHI or RDI is calculated based on less than two hours of continuous
recorded sleep, the total number of recorded events to calculate the AHI or RDI
during sleep testing is at least the number of events that would have been required in
a two hour period.
7) Apnea is defined as a cessation of airflow for at least 10 seconds. Hypopnea is defined
as an abnormal respiratory event lasting at least 10 seconds with at least a 30%
reduction in thoracoabdominal movement or airflow as compared to baseline, and with
at least a 4% oxygen desaturation.
8) Coverage with Evidence Development (CED)
Medicare provides limited coverage for CPAP in adult beneficiaries who do not
qualify for CPAP coverage based on criteria 1-7 above. A clinical study seeking
Medicare payment for CPAP provided to a beneficiary who is an enrolled subject in
that study must address one or more of the following questions:
In Medicare aged subjects with clinically identified risk factors for OSA, how does
the diagnostic accuracy of a clinical trial of CPAP compare with PSG and Type II,
III & IV HST in identifying subjects with OSA who will respond to CPAP?
In Medicare aged subjects with clinically identified risk factors for OSA who have
not undergone confirmatory testing with PSG or Type II, III & IV HST, does
CPAP cause clinically meaningful harm?
The study must meet the additional standards outlined in the NCD for Continuous
Positive Airway Pressure CPAP Therapy For Obstructive Sleep Apnea (OSA) (240.4).
The list of Medicare approved clinical trials is available at
http://www.cms.gov/Medicare/Coverage/Coverage-with-Evidence-
Development/CPAP.html. (Accessed April 4, 2018)
For payment rules for NCDs requiring CED, see the Coverage Summary for
Experimental Procedures and Items, Investigational Devices and Clinical Trials.
See the NCD for Continuous Positive Airway Pressure CPAP Therapy For Obstructive
Sleep Apnea (OSA) (240.4). (Accessed April 4, 2018)
Local Coverage Determinations(LCDs) for all states exist and compliance with these LCDs
is required where applicable. See the DME MAC LCDs for LCD for Positive Airway
Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (L33718). (Accessed
April 4, 2018)
Also see the DME MAC Positive Airway (PAP) Devices – Supplier Frequently Asked
Questions:
• CGS Administrators at
https://www.cgsmedicare.com/jc/pubs/news/2009/0909/cope10618b.html.
(Accessed April 4, 2018)
• Noridian Healthcare Solutions at
https://med.noridianmedicare.com/web/jddme/dmepos/pap.
(Accessed April 4, 2018)
b. Respiratory Assist Devices including Bilevel Positive Airway Pressure (BiPAP)
Medicare does not have a National Coverage Determination (NCD) for Respiratory
Page 6 of 12
UHC MA Coverage Summary: Sleep Apnea: Diagnosis and Treatment
Proprietary Information of UnitedHealthcare. Copyright 2018 United HealthCare Services, Inc.
Assist Devices.
Local Coverage Determinations (LCDs) for all states exist and compliance with these
LCDs is required where applicable.
For coverage guidelines, refer to the DME MAC LCD for Respiratory Assist Devices
(L33800).
Committee approval date: September 19, 2017
Accessed April 4, 2018
c. Mandibular Devices/Oral Appliances
Medicare does not have a National Coverage Determination (NCD) for Mandibular
Devices/Oral Appliances for the treatment of OSA.
Local Coverage Determinations (LCDs) for all states exist and compliance with these
LCDs is required where applicable.
For coverage guidelines, refer to the DME MAC LCD for Oral Appliances for OSA
(L33611).
Committee approval date: September 19, 2017
Accessed April 4, 2018
d. Surgical Treatment
1) Radiofrequency Submucosal Ablation of the Soft Palate and/or Tongue Base
(CPT code 41530)
Medicare does not have a National Coverage Determination (NCD) for
radiofrequency sumucosal ablation of the soft palate and/or tongue base.
Local Coverage Determinations (LCDs) exist and comliance with these LCDs is
required where applicable. Refer to the LCD Availability Grid (Attachment B).
For states with no LCDs, refer to the UnitedHealthcare Medical Policy for
Obstructive Sleep Apnea Treatment for coverage guidelines. (IMPORTANT
NOTE: After searching the Medicare Coverage Database, if no state LCD or
Local Article is found, then use the above referenced policy.)
Committee approval date: September 19, 2017
Accessed April 4, 2018
2) Other Surgical Treatments
Medicare does not have a National Coverage Determination (NCD) for other
surgical treatments of OSA.
Local Coverage Determinations (LCDs) exist and compliance with these LCDs is
required where applicable. Refer to the LCD Availability Grid (Attachment C).
For states with no LCDs, refer to the UnitedHealthcare Medical Policy for
Obstructive Sleep Apnea Treatment UnitedHealthcare Medical Policy for
Obstructive Sleep Apnea Treatment for coverage guidelines. (IMPORTANT
NOTE: After searching the Medicare Coverage Database, if no state LCD or
Local Article is found, then use the above referenced policy.)
Committee approval date: September 19, 2017
Accessed April 4, 2018
3. The following examples of services that are not covered, but are not limited to:
a. Surgeries or treatments that are dental in nature; refer to the Coverage Summary for Dental
Services, Oral Surgery and Treatment of Temporomandibular Joint (TMJ).
Page 7 of 12
UHC MA Coverage Summary: Sleep Apnea: Diagnosis and Treatment
Proprietary Information of UnitedHealthcare. Copyright 2018 United HealthCare Services, Inc.
b. Electrosleep therapy; see the NCD for Electrosleep Therapy (30.4). (Accessed April 4,
2018)
c. Implantable Hypoglossal Nerve Stimulation (HGNS); also known as Inspire Upper
Airway Stimulation (CPT Codes 64568, 64569, 64570, 0466T - 0468T, and 95970)
Medicare does not have a National Coverage Determination (NCD) for hypoglossal
nerve stimulation for sleep apnea.
Local Coverage Determinations (LCDs) specifically for implantable hypoglossal nerve
stimulation exist and compliance with these LCDs is required where applicable. Refer
to the LCD Availability Grid (Attachment E).
For coverage guidelines, refer to the UnitedHealthcare Medical Policy for Obstructive
Sleep Apnea Treatment for coverage guidelines. (IMPORTANT NOTE: After
searching the Medicare Coverage Database, if no state LCD or Local Article is found,
then use the above referenced policy.)
Committee approval date: January 16, 2018
Accessed April 4, 2018
II. DEFINITIONS
III. REFERENCES
See above
IV. REVISION HISTORY
01/16/2018 Re-review with the following updates:
Guideline 1 (Oximetry Testing) – Updated the applicable LCDs to include the most
recent website links and effective dates related to the Cahaba-Palmetto jurisdiction
transition; no change in guideline.
Guideline 1.b.5 [Home Sleep Studies or Polysomnography (G0398, G0399, G0400,
95800, 95801, and 95806)] – Updated the applicable LCDs to include the most recent
website links and effective dates related to the Cahaba-Palmetto jurisdiction transition;
no change in guideline.
Guideline 3.c [Implantable Hypoglossal Nerve Stimulation (HGNS); also known as
Inspire Upper Airway Stimulation (CPT Codes 64568, 64569, 64570, 0466T - 0468T,
and 95970)] - Updated the applicable LCDs to include the most recent website links
and effective dates related to the Cahaba-Palmetto jurisdiction transition; no change in
guideline.
09/19/2017 Annual review with the following updates:
Guideline 1.a (Oximetry Testing) – removed the following language “(Important
Note): After searching the Medicare Coverage Database, if no state LCD or Local
Article is found, then use the above referenced policy.)” as it is a repetitive statement.
Guideline 1.b (Polysomnography and Sleep Studies)
Removed reference to the following LCDs as they are no longer available: “Sleep
Studies” and “Polysomnography and Sleep Studies for Testing Sleep and
Respiratory Disorders”
Page 8 of 12
UHC MA Coverage Summary: Sleep Apnea: Diagnosis and Treatment
Proprietary Information of UnitedHealthcare. Copyright 2018 United HealthCare Services, Inc.
Added reference to the following LCD: “Medicine: Home Sleep Testing (HST)”
Guideline 1.b.5 [Home Sleep Studies or Polysomnography (G0398, G0399, G0400,
95800, 95801, and 95806)] – new guideline to coverage summary.
Guideline 3.c [Implantable Hypoglossal Nerve Stimulation (HGNS); also known as
Inspire Upper Airway Stimulation (CPT Codes 64568, 64569, 64570, 0466T - 0468T,
and 95970)]
Updated title by removing CPT codes 64553, 64999, L8679, L8680, L8686 and
adding CPT codes 64568, 0466T - 0468T and 95970 to be consistent with the
coding updates effective 01/01/2017.
Updated language to state LCDs now exist and provided new LCD Availability
Grid.
09/20/2016 Annual review with the following updates:
Guideline 1 (Diagnosis of obstructive sleep apnea) – deleted the following examples
as there are no applicable Medicare reference found: diagnostic X-ray services, routine
diagnostic laboratory services, pharyngoscopy, pneumogram for infants 6 months or
younger on an outpatient basis, and multiple sleep latency test (MSLT)
Guideline 2 a (Continuous Positive Airway Pressure)
• Added the definition of CPAP and Apnea (moved from the Definition section)
• to align with the reference NCD language, deleted “The use of CPAP devices
must be ordered and prescribed by the licensed treating physician to be used in
adult patients with moderate to severe OSA.”; added “The sleep test must have
been previously ordered by the beneficiary’s treating physician and furnished
under appropriate physician supervision.”
• To align with the reference NCD language, updated the language under Coverage
with Evidence Development (CED)
Gideline 2.d (Surgical Treatment)
• Added guideline specific to Radiofrequency Submucosal Ablation of the Soft
Palate and/or Tongue Base (CPT code 41530)
Definitions
• Moved the following definitions to the applicable guideline section: Apnea,
CPAP, and hypopnea
• Deleted the following definitions as there are no applicable Medicare references
found: BiPAP, electrosleep study, mandibular devices, and polysomnography.
04/19/2016 Guideline #3.c [Implantable Hypoglossal Nerve Stimulation (HGNS); also known as
Inspire Upper Airway Stimulation (CPT Codes 64553, 64568, 64569, 64570, 64999,
95970, L8679-80, L8686)] – Added new guidelines to coverage summary.
03/15/2016 Re-review with updated reference link(s) of the applicable LCDs to reflect the
condensed link.
10/20/2015 Annual review with the following updates:
Guideline 1.g (Polysomnography and Sleep Studies) - Updated to include the
availability of additional Local Coverage Determinations (LCDs).
Guideline 2.b [Respiratory Assist Devices including Bilevel Positive Airway Pressure
(BiPAP)]
Page 9 of 12
UHC MA Coverage Summary: Sleep Apnea: Diagnosis and Treatment
Proprietary Information of UnitedHealthcare. Copyright 2018 United HealthCare Services, Inc.
Updated to state that all states now have LCDs
Detailed guidelines removed and added a reference link to the DME MAC LCDs.
Guideline 2.c (Mandibular Devices/Oral Appliances)
Detailed guidelines removed and added a reference link to the DME MAC LCDs.
04/21/2015 Guideline #2.a (Continuous Positive Airway Pressure)
Added reference link to the list of Medicare approved clinical trials.
Updated payment information; added reference link to the Coverage Summary for
Experimental Procedures and Items, Investigational Devices and Clinical Trials
for payment rules for NCDs requiring CED.
03/12/2015 Formatting change only.
11/18/2014 Guideline 2.d. Surgical Treatment - Changed default guideline for states with no
LCDs from Wisconsin LCD for Surgical Treatment of Obstructive Sleep Apnea (OSA)
(L30731) to the UnitedHealthcare Medical Policy for Obstructive Sleep Apnea
Treatment
Definitions
• Updated the definition of:
o Apnea: added reference link to the DME MAC Local Coverage Determination
(LCD) for Oral Appliances for Obstructive Sleep Apnea
o Bilevel Positive Airway Pressure (BiPAP): added reference link to the DME
MAC Local Coverage Determinations (LCDs) for Respiratory Assist Devices
o Continuous Positive Airway Pressure (CPAP): added reference link to the
DME MAC Local Coverage Determinations (LCDs) for Respiratory Assist
Devices.
o Electrosleep Therapy: added reference link to the NCD for Electrosleep
Therapy (30.4)
o Hypopnea:. added reference link to the DME MAC Local Coverage
Determination (LCD) for Oral Appliances for Obstructive Sleep Apnea
o Mandibular Devices: added reference link to the DME MAC Local Coverage
Determination (LCD) for Oral Appliances for Obstructive Sleep Apnea
o Polysomnography: added reference link to the NCD for Sleep Testing for
Obstructive Sleep Apnea (OSA) (240.4.1)
• Removed the definition of:
o Snoreplasty (not used within this coverage summary)
10/21/2014 Removed detailed DME Face-to-Face Requirement information and replaced with a
reference link to the DME, Prosthetics, Corrective Appliances/Orthotic and Medical
Supplies Grid.
04/15/2014 Guideline #2.a (Continuous Positive Airway Pressure) – added LCD Availability Grid
for Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep
Apnea.
10/24/2013 Annual review, no updates.
08/20/2013 Added a note pertaining to the DME Face-to-Face Requirement in accordance with
Section 6407 of the Affordable Care Act as defined in the 42 CFR 410.38(g).
10/31/2012 Annual review with the following updates:
Page 10 of 12
UHC MA Coverage Summary: Sleep Apnea: Diagnosis and Treatment
Proprietary Information of UnitedHealthcare. Copyright 2018 United HealthCare Services, Inc.
• Guidelines #1.f (Oximetry Testing) updated to include additional information
pertaining to documentation requirement for Continuous Overnight Oximetry
(94762).
• Guidelines #2.d (Surgical Treatment) updated to state that there is only one
contractor with LCDs for Surgical Treatment of OSA.
09/06/2012 Guidelines #2.a Continuous Positive Airway Pressure updated to include the reference
and links to the DME MAC Positive Airway (PAP) Devices – Supplier Frequently
Asked Questions.
10/13/2011 Annual review with the following updates:
• Guidelines #1.f (Oximetry Testing) updated, i.e., changing the basis for default
guidelines for states with no LCDs from CIGNA LCD, L6465 to Palmetto LCD,
L31755.
• Guidelines #2.c (Mandibular Devices/Oral Appliances) updated, i.e., deleting the
default guidelines based on LCDs (Noridian L19078 & L24373) for states with no
LCDs and adding the coverage guidelines for all states based on the 4 DME MAC
LCDs for Oral Appliances for OSA.
• Guidelines #2.d (Surgical Treatment) updated, i.e., changing the basis for default
guidelines for states with no LCDs from Noridian LCDs, L19078 & L24373 and
Palmetto LCD, L28307 to Wisconsin LCD, L30731.
02/21/2011 Updated Guidelines #2.b - Bilevel Positive Airway Pressure (BiPAP) and other
Respiratory Assist Devices to include the note pertaining to the new CMS instruction
on the Elimination of Least Costly Alternative Language (effective February 4, 2011).
11/16/2010 Title changed from “Obstructive Sleep Apnea” to “Sleep Apnea – Diagnosis and
Treatment”.
Updated the following: Guidelines #1.g Polysomnography and Sleep Studies,
Guidelines #2.b Bilevel Positive Airway Pressure (BiPAP) and other Respiratory
Assist Devices, Guidelines #2.c Mandibular Devices/Oral Appliances and Guidelines
#2.d Surgical Treatment.
Deleted the following: Guidelines #3.a Sleep therapy/hypnosis (no CMS reference),
Guidelines #3.c LAUP (now addressed in #2.d), #3.d Somnoplasty (now addressed in
#2.d) and #3.e Mandibular Devices (now addressed in #2.c) and #3.g Snoreplasty (no
CMS reference).
V. ATTACHMENT(S)
Attachment A - LCD Availability Grid
Oximetry Services (Pulse Oximetry) CMS website accessed April 4, 2018
IMPORTANT NOTE: Use the applicable LCD based on member’s residence/place of service AND type of service.
LCD ID LCD Title Contractor Type Contractor States
L33446 Respiratory Therapy and
Oximetry Services
A and B MAC Palmetto GBA AL, GA, NC, SC, TN, VA, WV
L35434 Oximetry Services A and B MAC Novitas Solutions, Inc. AR, CO, DC, DE, LA, MD, MS, NJ,
NM, OK, PA, TX
End of Attachment A
Page 11 of 12
UHC MA Coverage Summary: Sleep Apnea: Diagnosis and Treatment
Proprietary Information of UnitedHealthcare. Copyright 2018 United HealthCare Services, Inc.
Attachment B - LCD Availability Grid
Radiofrequency Submucosal Ablation of the Soft Palate and/or Tongue Base CMS website accessed April 4, 2018
IMPORTANT NOTE: Use the applicable LCD based on member’s residence/place of service AND type of service.
LCD ID LCD Title Contractor Type Contractor States
L34526 Surgical Treatment of
Obstructive Sleep Apnea
(OSA)
MAC Part A Wisconsin Physicians Service
Insurance Corporation
AK, AL, AR, AZ, CT, FL, GA, IA, ID,
IL, IN, KS, KY, LA, MA, ME, MI,
MN, MO, MS, MT, NC, ND, NE, NH,
NJ, OH, OR, RI, SC, SD, TN, UT, VA,
VI, VT, WA, WI, WV, WY
L34526 Surgical Treatment of
Obstructive Sleep Apnea
(OSA)
MAC Part B Wisconsin Physicians Service
Insurance Corporation
IA, IN, KS, MI, MS, NE
L33777 Noncovered Services MAC Part A and B First Coast Service Options,
Inc.
FL, PR, VI
L36954 Noncovered Services other
than CPT® Category III
Noncovered Services
A and B MAC Palmetto GBA NC, SC, VA, WV
AL, GA, TN
End of Attachment B
Attachment C - LCD Availability Grid
Other Surgical Treatments of Obstructive Sleep Apnea (OSA) CMS website accessed April 4, 2018
IMPORTANT NOTE: Use the applicable LCD based on member’s residence/place of service AND type of service.
LCD ID LCD Title Contractor Type Contractor States
L34526 Surgical Treatment of
Obstructive Sleep Apnea
(OSA)
MAC Part A Wisconsin Physicians Service
Insurance Corporation
AK, AL, AR, AZ, CT, FL, GA, IA, ID,
IL, IN, KS, KY, LA, MA, ME, MI,
MN, MO, MS, MT, NC, ND, NE, NH,
NJ, OH, OR, RI, SC, SD, TN, UT, VA,
VI, VT, WA, WI, WV, WY
L34526 Surgical Treatment of
Obstructive Sleep Apnea
(OSA)
MAC Part B Wisconsin Physicians Service
Insurance Corporation
IA, IN, KS, MI, MS, NE
End of Attachment C
Attachment D - LCD Availability Grid
Home Sleep Studies or Polysomnography (G0398, G0399, G0400, 95800, 95801, and 95806) CMS website accessed April 4, 2018
IMPORTANT NOTE: Use the applicable LCD based on member’s residence/place of service AND type of service.
LCD ID LCD Title Contractor Type Contractor States
L35050 Outpatient Sleep Studies A and B MAC Novitas Solutions, Inc. AR, CO, DC, DE, LA, MD, MS, NJ,
NM, OK, PA, TX
L36902 Polysomnography and Other
Sleep Studies
A and B MAC CGS Administrators, LLC KY, OH
L34040 Polysomnography and Other
Sleep Studies
A and B MAC Noridian Healthcare Solutions,
LLC
AK, AZ, ID, MT, ND, OR, SD, UT,
WA, WY
L36861 Polysomnography and Other
Sleep Studies
A and B MAC Noridian Healthcare Solutions,
LLC
CA-ENTIRE STATE, AS, GU, HI,
MP, NV
Page 12 of 12
UHC MA Coverage Summary: Sleep Apnea: Diagnosis and Treatment
Proprietary Information of UnitedHealthcare. Copyright 2018 United HealthCare Services, Inc.
Attachment D - LCD Availability Grid
Home Sleep Studies or Polysomnography (G0398, G0399, G0400, 95800, 95801, and 95806) CMS website accessed April 4, 2018
IMPORTANT NOTE: Use the applicable LCD based on member’s residence/place of service AND type of service.
L36839 Polysomnography and Other
Sleep Studies
MAC Part A Wisconsin Physicians Service
Insurance Corporation
AK, AL, AR, AZ, CT, FL, GA, IA, ID,
IL, IN, KS, KY, LA, MA, ME, MI,
MN, MO, MS, MT, NC, ND, NE, NH,
NJ, OH, OR, RI, SC, SD, TN, UT, VA,
VI, VT, WA, WI, WV, WY
L36839 Polysomnography and Other
Sleep Studies
MAC Part B Wisconsin Physicians Service
Insurance Corporation
IA, IN, KS, MI, MS, NE
L33405 Polysomnography and Sleep
Testing
MAC Part A and B First Coast Service Options,
Inc.
FL, PR, VI
A53019 Polysomnography and Sleep
Studies – Medical Policy
Article
MAC Part A and B National Government
Services, Inc.
NY-ENTIRE STATE, MA, ME, NH,
RH, VT
End of Attachment D
Attachment E - LCD Availability Grid
Implantable Hypoglossal Nerve Stimulation (HGNS); also known as Inspire Upper Airway Stimulation
(CPT Codes 64568, 64569, 64570, 0466T-0468T, and 95970) CMS website accessed April 4, 2018
IMPORTANT NOTE: Use the applicable LCD based on member’s residence/place of service AND type of service.
LCD ID LCD Title Contractor Type Contractor States
L33777 Noncovered Services MAC Part A and B First Coast Service Options,
Inc.
FL, PR, VI
L36219 Non Covered Services A and B MAC Noridian Healthcare Solutions,
LLC
CA-ENTIRE STATE, AS, GU, HI,
MP, NV
L34555 Non-Covered Category III
CPT Codes
A and B MAC Palmetto GBA NC, SC, VA, WV
AL, GA, TN
L33392 Category III CPT® Codes MAC Part A and B National Government
Services, Inc.
NY-ENTIRE STATE, MA, ME, NH,
RH, VT
L35008 Non-Covered Services A and B MAC Noridian Healthcare Solutions,
LLC
AK, AZ, ID, MT, ND, OR, SD, UT,
WA, WY
L35094 Services That Are Not
Reasonable and Necessary
A and B MAC Novitas Solutions, Inc. AR, CO, DC, DE, LA, MD, MS, NJ,
NM, OK, PA, TX
End of Attachment E